Chapter 12: Nutrition Support Flashcards by Lisa Conticello

Prevalence of malnutrition in the oncology population has a wide range, ____ - _____%

30-85%

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EN is most appropriate for those who are ___________ or unexpected to be able to ingest/absorb adequate nutrients for more than ____ - _____ days

7-14

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T/F: According to ASPEN patients undergoing major cancer operations do not benefit from routine use of EN

True

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Perioperative nutrition may be beneficial in those malnourished if administered _____ - ____ days preoperatively, but this must be weighed against potential risks of delayed surgical intervention

7-14

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EN uses first-pass metabolism in the __________, which can promote more efficient nutrient utilization and reduces the risk of bacterial translocation when compared with PN

liver

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T/F: GI obstructions, GI bleeds, bowel ischemia, and active peritonitis are contraindications for EN

True

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The ligament of Trietz is the landmark area of separation between ____ & _______

Duodenum & jejunum

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PEG-J - benefits and how do you feed into it?

Feed into the jejunum only, must use a continuous pump. The g tube is used to reduce stomach contents. This can decrease risk for aspiration of gastric contents.

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Short-term enteral access (NG & NJ) are intended for how long?

~4-6 weeks

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These 2 feeding tubes must be placed surgically

j tube (not PEJ) & low-profile button

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Low profile button (MIC-KEY) feeding tubes are less obtrusive but require ___________ for administration

Extension sets

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Standard formulas AKA _______________ formulas are appropriate for the majority of cancer patients

Polymeric

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All tubes into the intestine decrease the risk for….

Aspiration of gastric contents

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Most EN formulas provide _______ - ______% of the body’s required free water

70-85%

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Provide a minimum flushes of ______ mL at least every _____ hours during continuous feeds for patency

30 mL q 4 hours

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Blenderized tube feeding requirements:
-Hang time:
-Type of tube:
-Side of tube
-Method of administration

Hang time: 2 hours
Type of tube: G
Size of tube: at least 14 French
Method: must be able to tolerate bolus

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4 primary methods of EN administration

Bolus
Intermittent (gravity)
Cyclic
Continuous

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Semi-elemental formulas are AKA

Peptide-based

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Standard EN formulas provide ~15-25% kcal from protein while renal formulas provide….

7-18% kcal from protein

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Renal formulas are more concentrated (lower in water), and have reduced amounts of these 4 minerals

Sodium, potassium, phosphorus, calcium

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Pulmonary formulas are lower in ______ but higher in _____

lower in CHO, higher in fat
moderate protein (16-18%)

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Immune-modulating formulas are often higher in _______

Protein

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The 2 most commonly use modular components are

Protein & fiber

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Refeeding syndrome can occur when malnourished patients are initially fed full-energy feeds or high ______ diets

carbohydrate

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Hallmark signs of refeeding -- _____ retention - ______ dysfunction - _______ failure

Fluid retention, cardiac dysfunction, respiratory failure

Taking NPO for > _____ days increases risk for refeeding

_____ is an important cofactor in CHO metabolism, thus supplementation of ______ mg for ____ - ____ days can help prevent refeeding syndrome

Thiamine 100 5-7 days

ASPEN recommends not routinely monitoring for residual volumes. Do not hold if GRV is < _____ mL in the absence of other symptoms

500 mL

Recommended initiation rate for bolus or intermittent feeds

60-120 mL

Initiation rate for cyclic or continuous feeds

10-40 mL/hour

Advancement schedule for bolus/intermittent feeds

Increase by 60-120 mL every 8-12 hours (or every 1-2 feeds)

Advancement schedule for cyclic/continuous feeds

Increase by 10-20 mL/hour every 8-12 hours or 4-24 hours (respectively)

If dehydrated, you may wish to switch to a less _____ formula

concentrated (thus higher in free water)

Hypernatremia is caused by one of 2 causes:

1. Inadequate free water 2. Excessive diuresis

SIADH causes low _______ 2 ways to correct _________

Sodium Restrict free water & diuresis`

Supplement w/ sodium if the cause of hyponatremia is ________

GI losses

Metabolic acidosis _______ concentration of potassium in the blood

increases

T/F: Insulin raises phosphorus & potassium in the blood

False, lowers and could cause hyponatremia/hypophosphatemia

Tumor lysis syndrome is characterized by (high/low) levels of potassium & phos

High

To prevent aspiration, the HOB should be

30-45 degrees

Small bore tubes may increase risk for clogs but decrease risk for

Aspiration

_______ agents are beneficial for aspiration, GERD, and nausea

Prokinetics

If bacterial contamination is the cause of diarrhea....

Educate on hang times, change tubing frequently, switch to a closed system

Is prune juice appropriate for constipation with EN?

Yes

Suspend EN for constipation when _______ is supected

Obstruction or illeus

Small diameters tubes are considered

8-10 French and increase risk for clogs

The most common G-tube complication is....

Peristomal infection (leakage is also common but underreported)

5 strategies for managing a clogged EAD

1. Warm water instillation for up to 15 minutes 2. Push pull method with syringe 3. Pancrealipase + sodium bicarb mixture (baking soda) 4. Commercial unclogging device (mechanical) 5. Commercial unclogging solution (i.e TubeClear or Clog Zapper) - use under medical supervision

Hyperosmolar meds (>1000 mg/kg) through tube

dilute with 10-30 mL water to reduce GI effectd

Instead of cholestyramine through feeding tube for anti-diarrhea, use hydrolyzed _______ ____

Guar gum to thicken the stool)

These 2 anti-emetics can not be put through the feeding tube

Aprepitant and orally disintegrating Ondansetron Put ondansetron in mouth to dissolve or use alternatives

These antibiotics cannot but put through feeding tube and there's no alternatives

Fluoroquinololones (Cirpofloxacin, Levofloxacin)

This appetite stimulant cannot be put through the feeding tube

Dronabinol

This solid form of opiod cannot be put through feeding tube

Oxycodone (switch to liquid)

Should you put psyllium or methylcellulose through feeding tube?

NO nor should you put bisacodyl tables (consider suppository or liquid forms)

Avoid these tablet forms of PPIs through feeding tube

Pantoprazole & Rabeprazole (Lansoprazole & Esomperazole OK)

This H2 agaonist may bind to protein left in feeding tube and create clogs

Sucralfate

Those who would die from __________ before tumor progression could be considered for EN

Malnutriiton

Is central parenteral nutrition or peripheral parenteral nutrition preferred?

Central Lower infectious rate, better for long term. Usually already have central access via port but would benefit from a separate line. PICC = peripherally inserted central catheter

5 Reasons for PN

1. Illeus (possibly post-op) 2. Malignant bowel obstruction 3. High output distal GI fistula (>200 mL/day) 4. Inability to tolerate EN for > 7-14 days 5. Refractory diarrhea, large volume

_______ is the primary source of energy source with PN and a minimum of _________ g/day is needed to prevent ketosis

Dextrose 50 g (but ideally no less than 100-150 g/day is recommended)

SMOFlipid was approved in 2016 as an alternative to soy-based only lipid emulsions. This contains

Soybean, MCT oil, Olive oil, Fish oil Higher in vitamin e but not excessive

Omegaven was approved in 2018 and contains 100% ______ oil, which has shown to improve PN liver disease in the pediatric population

fish oil

ASPEN recommends providing at least ______% energy from linoleic acid & ______% energy from linolenic acid to prevent deficiency

1-2% 0.5%

PN products are often deficient in vitamin ________

_____ is not routinely added to PN d/t concern for adverse reactions and incompatibility issues

Iron, thus periodic iron infusions mahy be needed

It's acceptable to mix some medications into PN including

Regular human insulin, famotidine, and heparin

2 in 1 vs 3 in 1 PN mixtures

2 in 1 is dextrose + AAs, then "piggyback" of fats -lipids are less stable (12 hour hang time) 3 in 1 is "total nutrient mixture" (fat, cho, amino acids) - longer hang time but next to mix the lipids in right before

kcal/kg recommendation for PN with refeeding syndrome risk

15 kcal/kg (20-30 kcal/kg if stable)

To prevent hyperglycemia, EN should be provided with _____ - _____ g dextrose or ______ for those with already poor glycemic control

150-200 100

When PN has started, begin with 24 hour infusion. Then can consider a cyclic regimen of ______ - ____ hours/day

12-16

Long-term PN complications

Mirconutrient toxicities or deficiencies, organ dysfunction, metabolic bone disease

Short-term PN complications

uncontrolled BG, hypertriglyceridemia, fluid/electrolyte imbalances (more common w/ PN than EN)

Once the patient is meeting ______% needs via enteral or oral route, the PN can be safely discontinued

60%

Daily monitors w/ new PN

weight, i/os, BMP + phos & mg, glucose (q6 hours until stable)

Weekly labs w/ new PN

CBC, LFTs

If unable to tolerate fats in PN, consider these alternative modes of administration

Topical & oral ingestion

Define Azotemia

Excessive BUN & protein components in blood (may be d/t dehydration or excess amino acids)

Soy-based fat emulsions may cause liver disease & ________

Immunosuppression (increased infectious risk) *avoid lipids with critically ill during week 1

If experiencing hyperglycemia, limit CHO to ____-_____ mg/body wt or ___ - _____ kcal/kg

4-5 mg/kg 20-25 kcal/kg

Hypertrigylceridemia w/ PN may be d/t ________ or ________

excess dextrose OR rapid infusion of lipids

Rise of these enzymes within the first 2 weeks of PN is normal and should be monitored

Liver (ALT & AST)

minimum requirement for lipids

250 ml of 20% IVFE twice per week

Chapter 12: Nutrition Support Flashcards

(84 cards)